Sharing Lessons Learned

What the nurses remember most is the smell of blood and iron and steel recalls Dorita Sondereker, RN, Administrative Director of Emergency Services at Sunrise Hospital in Las Vegas. The floor was solid red. People kept slipping in the sea of blood. Sunrise Hospital, a level II trauma Center, treated 214 patients of the hundreds injured at the Route 91 Harvest country music festival in Las Vegas last October, including 124 with gunshot wounds.

Sondereker and her colleague, trauma surgeon Dr. Dave MacIntyre spent several days in New Orleans sharing their lessons learned responding to the deadliest mass shooting in modern US history. LSU Health emergency medicine physicians and trauma surgeons at UMC, showed the team the set-up of the Level I trauma center and Emergency Department, participated in the pair’s presentation to a large group including first responders, and then met the following day to further discuss mass casualty planning.

Among the lessons shared was that patients will arrive at the hospital any way they can. Besides ambulances that were carrying up to six wounded, patients arrived stuffed into police cruisers, as well as via Lyft, Uber, pickup trucks and private vehicles. Siri was who people called, not 911. They wanted directions to the nearest hospital.

Dr. MacIntyre cautioned that the proximity of two other hospitals to UMC could cause confusion and cost time. People need to know that critically wounded people belong at the Level I Trauma Center, and they need to know where it is. At Sunrise patients not only didn’t come to the right entrance, some went to the wrong building. And time is life.

Sunrise threw standard protocols out of the window. With that many patients, you have to adapt.

To save precious time, nurses circumvented paperwork filling their pockets with O-negative blood and intubation drugs.

It was all hands on deck, and people were pressed into service, some doing jobs not traditionally theirs. Anesthesiologists helped provide nursing care and nurses took on a larger triage role.

An important lesson shared came from MacIntyre. “We didn’t do ATLS (advanced trauma life support). We did military triage and tactical combat casualty care, and that’s why we were successful.”

The Las Vegas team shared what they learned about smaller things that can loom large. Simply raising the head on empty stretchers can prevent having to reposition critically wounded patients loaded the wrong way, something MacIntyre had to handle by himself.

Calm teamwork and heart also contributed to Sunrise’s success in managing such a large number of critically injured patients at once. Sondereker described a calmness through the chaos and a camaraderie as they all worked their hearts out.

Sunrise surgeons performed 58 surgeries in the first 24 hours, 83 altogether.

"We always need to plan for the unexpected," said LSU Health New Orleans trauma surgeon Dr. Lance Stuke, who practices at the Level I Trauma Center at UMC. "This event has taught us that if a scenario seems unrealistic, then we should probably plan for it. At our institution we need to practice rapidly opening up all operating rooms in the middle of the night for severely injured casualties. Additionally we need to incorporate the surgery residents into our disaster planning. As this event demonstrated, the surgery residents were vital in providing manpower for assessing and operating on these critically injured patients."

Dr. Stuke's biggest takeaway was how quickly a well developed trauma system can still get overwhelmed with multiple battlefield-type casualties and how important even basic skills can be. "The trauma team was forced to resort to using the bare essentials. The take-home message is that basic trauma skills made a significant impact in saving lives.

Stuke found a lot of value in interacting with those who have been through it. "This program was a great learning tool for us to see what worked and what didn't work in a mass casualty event. Trauma centers around the country are facing a similar learning curve as the number of mass shootings continues to rise."

LSU Health New Orleans Associate Clinical Professor of Emergency Medicine and Public Health and Assistant Director of the Internal Medicine/Emergency Medicine Residency Program Dr. James Aiken also serves as Medical Director of Emergency Preparedness at UMC. He has been involved in planning for mass casualty incidents for many years, including for the first Super Bowl in New Orleans after Katrina. The planning has been put to the test, most recently after dozens of people at the Endymion parade were hit by a pickup truck last year.

“I'm very pleased that I and the University Medical Center emergency management team were able to meet and work with Dorita Sondereker, RN, and Dr. Dave MacIntyre,” said Dr, Aiken. “Their presentation to a wide hospital and LSU Health audience, as well as our meeting with Ms. Sondereker, gave our LSU Health campus and hospital valuable opportunities to share our mass casualty plans and lessons learned to enhance our preparedness for such an event. The benefit of being able to learn from those who have firsthand knowledge of an event we can only imagine was immeasurable. There is no substitute for experience.”